Forehead Lift Procedure Gets Thumbs Up

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The endoscopic forehead-lift as an alternative procedure to the commonly performed coronal forehead-lift has gained popularity in recent years. This study reports evaluations of the long-term results with the procedure.

Note that the study suggests that the procedure is associated with long-lasting results and with a high satisfaction score by patients.

Most patients undergoing an endoscopic procedure to eliminate forehead furrows indicated they were highly satisfied with the long-term results, researchers said.

Among 98 patients who underwent the procedure from 1994 to 2007 and were contacted an average of 38 months later (range 9 to 108 months), the mean satisfaction score on a 0-10 scale was 7.1, reported Nikolaos A. Papadopulos, MD, PhD, of Munich Technical University in Munich, and colleagues.

Because the procedure lifts the eyebrows along with smoothing wrinkles in the forehead, measurements of midpupil-to-eyebrow distances before and after surgery provide a means of quantifying results, the researchers explained in their report in the Sept./Oct. issue of Archives of Facial and Plastic Surgery.

"Long lasting results are achieved [as evidenced by] a mean midpupil-to-eyebrow elevation of 5.6 mm in a relaxed position after 5.5 years," Papadopulos and colleagues wrote.

The endoscopic procedure was first introduced in 1992, when coronal lifts were then the dominant way to eliminate forehead wrinkles.

With the endoscopic lift, as practiced in the authors' Munich clinic, the surgeon makes at total of four to six 1-cm incisions about 2 cm behind the hairline. "Two incisions are placed in a paramedian plane, and two further incisions are made in the parietotemporal region," the researchers explained. If more access is needed, another two incisions may be placed in the temporal region.

Instruments are then inserted through the incisions to separate the forehead skin from its substructure, with the subperiosteal dissection performed by endoscopy. Corrugator and procerus muscles are removed and the forehead skin then repositioned and anchored with a specially designed screw that is removed a week later.

Papadopulos and colleagues indicated that they began performing forehead lifts with this procedure in 1994. For the current analysis, they attempted to follow up with 143 patients they had treated in this way, with a questionnaire and a request to have their faces photographed. Preoperative photographs were available for comparison in these patients.

A total of 98 completed the questionnaires and 52 who had been been operated on at least 2 years previously submitted to the photographic exam. In the exams, photos were taken in three facial positions: relaxed, lifting their eyebrows, and frowning.

Questionnaire responses indicated that most patients suffered significant pain, bruising, and swelling in the first month after surgery, but only about 14% continued to experience such effects during the second month.

However, long-lasting numbness in the scar area and in the forehead itself was a common problem, the researchers found. Numbness at the scars more than 6 months after surgery was reported by 41% of respondents and in the forehead by 35%.

Despite the adverse effects, though, most patients indicated they were satisfied with the results. Asked if they would undergo the procedure again, 45% answered with a definitive Yes and 18% said they "likely" would. About 18% were unhappy, responding "never" or "unlikely."

A question of whether patients would recommend the procedure to others elicited a similar distribution of responses.

The study showed that the procedure does not permanently stave off the pull of gravity. There was a close, negative correlation between time since surgery and post-surgical elevation in eyebrows relative to preoperative position. Patients evaluated 24 months after surgery had about a 9-mm elevation, whereas those examined after 108 months had an elevation of 3 mm (P=0.005 for trend).

These data indicated "a general, gradual drop of brow position over 5 years," averaging almost 1 mm per year, the researchers wrote.

At least in the early stages, though, such a drop may be desirable. A set of full-face photographs included with the report indicate that the postoperative eyebrow elevation can leave patients with a look of surprise.

Passage of time did not appear to affect other measures of eyebrow position, such as their horizontal separation or in the pupil-to-eyebrow distance when frowning or deliberately lifting their eyebrows.

Papadopulos and colleagues acknowledged that the eyebrow-based measurements were difficult to standardize because of variations in natural eyebrow shape and the habit of some patients to trim their brows.

Other limitations to the analysis included its retrospective design and incomplete patient follow-up.

"Further additional prospective studies for evaluation of long-term results on a larger number of patients, as well as long-term evaluations of different fixation techniques and in comparison with the coronal approach, are needed," the researchers wrote.

The study had no external funding.

Study authors declared they had no relevant financial interests.

Reviewed by Zalman S. Agus, MD Emeritus Professor, Perelman School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA, BSN, RN, Nurse Planner

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